post extraction complication

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Diagnosis andManagement of

Common Postextract ionComplicat ions

Joseph E. Pierse, DMD, MA, Harry Dym, DDS*, Earl Clarkson, DDS

Extraction of impacted teeth is one of the most common surgical procedures per-formed by oral and maxillofacial surgeons. Extensive training, skill, and experienceare necessary to perform this procedure with minimal trauma to the surroundingsoft and hard tissue. When the clinician is untrained or inexperienced, the incidenceof complications rises exponentially. 1–3 Treatment planning for the removal of asymp-tomatic teeth is no less problematic. In many situations the course of treatmentdepends on the clinician’s experience, professional judgment, and knowledge of current evidence-based literature.

Every surgical procedure results in some degree of postoperative bleeding andinflammation, typically manifesting as pain and edema. Through the inflammatoryresponse and the natural progression of the body to heal itself, wound repair andtissue regeneration are activated, and physiologic mediators are concentrated inthe wound area, resulting in the induction of nociceptive pathways and a change invascular permeability. Although the complex physiology of the human body is beyondthe scope of this article, the educated clinician should have an understanding of thetime line associated with these processes so as to determine whether a patient’scomplaint of postoperative bleeding, pain, or swelling represents a normal responseto surgical trauma or an aberrant reaction. 4

SURGICAL DAMAGE TO ADJACENT STRUCTURES

Occasionally an impacted tooth is located such that its removal may seriouslycompromise adjacent vital structures, making it prudent to leave the impacted toothin situ. The potential risks, benefits, and alternatives must be discussed thoroughly

Department of Dentistry/Oral & Maxillofacial Surgery, The Brooklyn Hospital Center, 121DeKalb Avenue, Box 187, Brooklyn, NY 11201, USA* Corresponding author.E-mail address: [email protected]

KEYWORDS

Diagnosis Management Postextraction complications Impacted teeth

Dent Clin N Am 56 (2012) 75–93doi: 10.1016/j.cden.2011.09.008 dental.theclinics.com0011-8532/12/$ – see front matter 2012 Elsevier Inc. All rights reserved.

mailto:[email protected]://dx.doi.org/10.1016/j.cden.2011.09.008http://dental.theclinics.com/http://dental.theclinics.com/http://dx.doi.org/10.1016/j.cden.2011.09.008mailto:[email protected]


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with the patient before consent. At the completion of development, full bony impactedthird molars may be positioned in close proximity or through the inferior alveolar nervecanal. It may be prudent to leave the impacted tooth (if asymptomatic) in place and notrisk paresthesia or anesthesia of the inferior alveolar nerve. Surgical extraction of impacted third molars can result in significant bony defects that may not healadequately in elderly or medically compromised patients and may result in the lossof adjacent teeth rather than the improvement or preservation of periodontal health.

EVALUATION AND DETERMINATION OF SURGICAL DIFFICULTY

Preoperative assessment of the third molar, both clinically and radiographically, isparamount during the surgical procedure for the removal of impacted teeth. Classifi-cation is based on the angulation of the impacted tooth, the relationship of theimpacted tooth to the anterior border of the ramus and the second molar, the depth

of the impaction, and the type of tissue overlying the impacted tooth. According tothe literature, the mesioangular impaction, which accounts for 45% of all impactedmandibular third molars, is the least difficult to remove. The vertical impaction (40%of all impactions) and the horizontal impaction (10%) are in term ediate in difficulty,whereas the distoangular impaction (5%) is the most difficult. 5–11

The relationship of the impacted tooth to the anterior border of the ramus indicatesthe space available for tooth eruption as well as the planned extraction. If the length of the alveolar process anterior to the anterior border of the ramus is adequate enough toallow tooth eruption, the tooth is generally easier to deliver. The depth of the impactionunder the hard and soft tissues is also an important consideration in determining the

degree of difficulty. Root morphology also plays a significant role. Root anatomy canbe either conical and fused, or separate and divergent, with the latter being more diffi-cult to manage. 5–11

Another important determinant of difficulty of extraction is the age of the patient.When impacted teeth are removed before the age of 20 years, there are fewer compli-cations. The roots are usually two-thirds formed, and often separated from the inferioralveolar nerve, therefore allowing minimal bone removal and fewer complicationsduring tooth extraction. There is usually a broader pericoronal space formed by thefollicle of the tooth, which provides additional access for tooth extraction without largequantities of bone removal. However, extraction of impacted teeth in patients of older

age groups (>40 years) proves to be more challenging, with increased risk of compli-cations. The longer roots are often completely formed, which requires more boneremoval, and their apical location is closer to the inferior alveolar canal, whichincreases the risk of postsurgical anesthesia or paresthesia. Furthermore, there isan increased density and decreased elasticity in the bone with age. 12

EXPECTED POSTOPERATIVE COURSE

Surgical removal of impacted third molars is associated with a moderate incidence of complications. These complications range from the expected and predictableoutcomes, such as edema, pain, trismus, and minor bleeding, to more severe andpermanent complications, including inferior alveolar nerve anesthesia and fractureof the alveolus. The overall incidence of complication and the severity of these compli-cations are proportional to the depth of the impaction. Extraction of impacted teeth inthe elderly or medically compromised patient is associated with a higher incidence of postoperative complications, especially alveolar osteitis, infections, mandible frac-ture, tooth fracture, sinus communication, and inferior alveolar nerve paresthesia. 13–17

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Another determinant of the incidence of complications of third molar surgery is therelative experience and training of the clinician. After the surgical removal of animpacted third molar, certain normal physiologic responses occur. These responsesinclude such sequelae as mild bleeding, edema, trismus, and pain. With experience,the oral and maxillofacial surgeon develops a n un derstanding as to how this surgicalprocedure affects the patient’s quality of life. 18,19 As expected, third molar removalhas a profoundly negative impact for the first 4 to 7 days after surgery, but longerfollow-up reveals improved quality of life, mostly resulting from the elimination of chronic pain and inflammation. 20

BLEEDING

Bleeding can be minimized by using an ideal surgical technique and by avoiding unto-ward force, the tearing of flaps, or excessive trauma to the overlying soft tissue. When

a vessel is cut or severed, the bleeding should be stopped by some measure toprevent secondary hemorrhage after surgery. The most efficient approach to obtain-ing hemostasis after surgery is to apply a moist gauze pack and have the patient bitedown directly over the site with adequate application of pressure.

The clinician can prevent excessive postoperative bleeding by meticulous tissuemanagement intraoperatively. However, in some patients, immediate postoperativehemostasis is difficult. In such situations a variety of measures can be used to promotelocal hemostasis, which include additional sutures, the application of topical thrombin,oxidized cellulose, chitosin bandage, absorbable gelatin sponge, and the use of a localanesthetic with epinephrine. Patients who have known acquired or congenital coagu-

lopathies require extensive preparation and preoperative planning.Postoperative bleeding is a common sequela of any dentoalveolar procedure. In

healthy patients, postoperative bleeding is typically minimal and self-limited by theclotting cascade of the body. The timeline for clot formation is typically 6 to 12 hourspostoperatively. Continuous active bleeding after the twelfth hour is consideredexcessive and should warrant concern. The patient should be taken to the emergencyroom for immediate attention.

It is important to distinguish and discuss the difference between active bleedingfrom surgical site and oozing. Patients are often concerned with excessive bleedingbecause they observed traces of blood in their saliva. Oozing should resolve within

36 to 72 hours postoperatively, and should respond positively to pressure. However,patients with a hemorrhagic bleed present with their mouth actively filling with bloodimmediately after removing the hemostatic dressing.

Among the most important measures in the management of excessive postopera-tive bleeding is recognition of the compromised patient. During the preoperativeassessment, a detailed medical history should be obtained, including disorders asso-ciated with coagulopathies, use of anticoagulants because of comorbidities, and anindividual or family history of bleeding affiliated with surgical procedures, excessivebleeding during exfoliation of deciduous teeth, and, in women, a history of menor-rhagia. Appropriate adjunct therapy, such as discontinuation of anticoagulant medica-tions, factor infusions, or use of clot-stabilizing pharmacotherapy, should beconsidered in patients with risk factors or known bleeding diatheses. 21,22

Patients on warfarin, for instance, pose a common problem for the clinician perform-ing surgical procedures. The underlying medical problem, like long-standing atrialfibrillation, deep vein thrombosis, prosthetic heart valve, or myocardial infarction,often prohibits discontinuing the anticoagulant. An acceptable management strategyis to hospitalize the patient, discontinue the medication, and maintain the patient on

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a step-down heparin regimen until the prothrombin time (PT)-international normalizedratio (INR) are at therapeutic levels.

Caution should be taken during treatment planning when considering the type of dentoalveolar surgery being performed. Many minor oral surgical procedures canbe performed while the patient is anticoagulated. 2 In general, for patients on warfarin,a PT-INR less than 2.5 is acceptable if multiple extractions are required. For extractionof 1 to 3 teeth, without posterior teeth or surgical extractions, an INR of less than 3.0 isacceptable. Therefore, for patients requiring multiple extractions, staged visits areappropriate to prevent discontinuation of the anticoagulants.

It is common to identify an incompletely formed clot, or liver clot. This clot is oftenmobile and continues to aggravate the surgical site. Careful removal of the clot is crit-ical to successfully promote hemostasis. As mentioned earlier, the use of vasocon-strictor anesthetics is appropriate once the source of bleeding has been identified.If the vasoconstrictor is applied to the area before the identification of the bleed, deter-mining the site of origin is complicated. The wound may need to be repacked witha local hemostatic agent and sutured. Arterial bleeds that cannot be controlled withlocal measures should be treated with ligation or electrocautery. If bleeding persists,embolization, proximal vessel ligation, or other endovascular procedures should beconsidered in conjunction with interventional radiology. 23,24

EDEMA

Postsurgical edema or swelling is an expected side effect of third molar surgery. Theonset of swelling is typically between 12 and 24 hours, with a peak incidence noted 48

to 72 hours postoperatively. Edema typically begins to subside at 4 days postopera-tively, with most patients experiencing complete resolution within 5 to 7 days. A coldcompress may be used to minimize the onset of edema and aid in the reduction of chronic throbbing pain. 23,25–27

It is important to educate patients of this time course and that edema is often antic-ipated. In addition, patients should be informed to sleep with their head elevated andnot to sleep on their side, to avoid any dependent swelling. Furthermore, perioperativesteroids may be used to prevent swelling in patients undergoing invasive procedures(ie, complete bony impacted third molar extraction). Perioperative steroids producemoderate to marked decreases in edema, but are short-acting in their effects

( Table 1 ).28–35

INFECTION

Another postsurgical complication related to the removal of impacted third molars isinfection. The i nc idence of infection after the removal of third molars is low, at only1.7% to 2.7%. 36 About 50% are localized subperiosteal abscess infections, whichoccur 2 to 4 weeks after an uneventful postoperative course. These infections areoften attributed to debris remaining under the mucoperiosteal flap. Treatment issimply surgical debridement and drainage. Of the remaining 50%, few postoperativeinfections are significant enough to warrant surgery, antibiotics, or hospitalization.Infections occur only within the first 7 days 0.5% to 1% of the time. 8 According tothe literature, this situation is considered an acceptable infection rate, which wouldnot warrant administration of prophylactic antibiotics. 37 The oral cavity harbors a broadspectrum of bacterial flora. Therefore, any intraoral wound is exposed to certainaerobic, anaerobic, and facultative organisms with pathogenic potential. The routineuse of antibiotics is used for the prevention of postoperative infections ( Table 2 ).38

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Table 2Antibiotics

Medication Indication CoverageAdult Dose/Route ofAdministration

Penicillin VK First line for odontogenicinfections

Streptococci, oral anaerobes 250–500 mg by mouth every6 h for 7 d

Cephalexin,cephadroxil

Need for bacteriocidal broadercoverage

Gram-positive cocci, somegram-negative rods, oralanaerobes

250–500 mg by mouth every6 h for 7 d

Amoxicillin Need for broad-spectruminfections >3 d

Gram-positive cocci, Escherichiacoli , Haemophilus influenzae ,oral anaerobes

250–500 mg by mouth every8 h or 500–875 by mouthevery 12 h for 7 d

Clindamycin Need for broad-spectrum, oralanaerobes, penicillin-allergicpatient

Gram-positive cocci, anaerobes 150–450 mg by mouth every6 h for 7 d


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more damage than benefit, when radiographic follow-up may be all that is required.When such excessive forces are applied to the tooth, the torque generated causesa fracture at the junction between that portion of the root still attached to the alveolarbone and that portion already released from the socket wall.

The prevention of root fractures is primarily based on meticulous surgical technique,minimizing excessive force, and ensuring that the dentition is adequately luxated,providing an atraumatic delivery. Recognition of teeth at risk for root fracture is alsoan important preventative measure. Multirooted posterior teeth, curved roots, anteriordentition with root dilacerations, or teeth with widely spaced, thin roots all pose anincreased risk for fracture. Thus, inadvertent root fractures can be avoided by prudenttreatment planning and sectioning of a tooth before elevation and removal. Once thetooth has been delivered, it should be examined carefully to confirm that the rootswere completely removed. Furthermore, it is important to reconstitute the fragmentsof a sectioned tooth to confirm that no remnants remain in the socket.

If a root fracture is noted, the socket should be irrigated copiously with normal saline,and an attempt should be made to directly visualize the retained root or root tip. Forteeth without preoperative evidence of periapical disease or infection, small root tips,less than 3 mm, can be retained without adverse effects. For posterior teeth, the riskof causing damage to the maxillary sinus or inferior alveolar nerve may often outweighthe risk of leaving the fragment in place. However, if there is associated disease with thetooth preoperatively, it is imperative that the root fragment be removed. Once the frag-ment is directly visualized, root tip picks or elevators should be used to separate thefragment from the alveolar socket without apical pressure. Gentle manipulation shouldbe used until the root is mobilized, at which point it can be delivered.

ALVEOLAR OSTEITIS

The incidence of alveolar osteitis or dry socket after the removal of impacted mandib-ular third molars is 3% to 30%. When dry socket is defined in terms of pain thatrequires the patient to seek follow-up, the incidence is between 20% and 25%. Thepathogenesis of alveolar osteitis has not been clearly defined, but the condition ismost likely the result of lysis of a fully formed blood clot before the clot is replacedwith granulation tissue, thus leaving the alveolar bone exposed. The process of fibri-nolysis occurs 3 to 4 days after extraction. Patients present with a severe throbbing,

radiating pain, often associated with a malodor from the surgical site, and trismus. Thesource of the fibrinolytic agents may come from tissue, saliva, or bacteria. 2,23,56–64

The incidence of dry socket is higher in patients with a social history of smoking.Female patients who take oral contraceptives are also at risk of alveolar osteitis. Itsoccurrence can be reduced by diminishing the bacterial contamination of the surgicalsite. This objective can be accomplished initially by presurgical rinsing with chlorohex-idine, which reduces the incidence of dry socket by up to 50%. Copious irrigation of the surgical site with normal saline throughout the procedure is also effective. The solu-tion to pollution is dilution. The use of topical medicaments, antibiotics like tetracycline,clot stabilizers (Gelfoam [Pfizer, Distributed by Pharmacia & UpJohn Company, Divisionof Pfizer INC., New York, NY, USA]), platelet-rich plasma, and medicated mouth rinseshave also been suggested for prevention of alveolar osteitis. 2,37,57–62,65–68

The treatment of the dry socket is palliative in nature during the delayed healingprocess. This treatment is usually accomplished by irrigation of the involved socket,gentle mechanical debridement, and placement of an obtundent dressing. Thedressing is changed daily for approximately 7 days. The pain usually resolves within3 to 5 days, although it may take as long as 10 to 14 days in some patients.

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The lack of fever, edema, or purulent discharge may help to distinguish alveolarosteitis from an infection. This distinction is important, because antibiotic treatmentdoes not resolve dry socket. Clinical findings may include a cryptlike socket withexposed bone and erythematous soft tissue margins, food debris or other detritusin the socket, and extreme tenderness to palpation. Radiographic examination shouldalso be obtained to rule out the presence of any retained tooth structure or othersurgical site complication, like alveolar fracture. Once a diagnosis of a dry sockethas been made, treatment should commence immediately. Because the condition isself-limiting, pain control ( Table 3 ) and increased oral hygiene are the primary goals.

PARESTHESIA/ANESTHESIA

Surgical removal of mandibular third molars places both the lingual and inferior alve-olar branches at risk for possible injury. The lingual nerve is most often injured duringsoft tissue flap reflection, whereas the inferior alveolar nerve is injured during theextraction process itself. According to the literature, the accepted incidence of injuryto the inferior alveolar and lingual nerves after third molar surgery is about 3%.Episodes of paresthesia should only be transient after routine surgical extractions.However, as many as 45% of nerve compression injuries, which are typical in thirdmolar surgery, result in a permanent neurosensory abnormality. 13–16,69–72

The most common predisposing factor is complete bony impaction of mandibularthird molar, involving mesioangular and vertical impaction predominantly. In somecases, nerve proximity to the root is indicated by an apparent narrowing of the inferioralveolar canal as it crosses the root or root dilaceration adjacent to the canal. Otherradiographic findings include diversion of the path of the canal by the tooth, darkeningof the apical end of the root (indicating that it is included within the canal), and discon-tinuity of the white line of the canal. 73

During the preoperative radiographic evaluation, the clinician should take extraordi-nary precautions to avoid injury to the nerve, such as additional bone removal orsectioning of the tooth. The patient should be thoroughly informed regarding theincreased risk of nerve injury. When an injury to the lingual or inferior alveolar nerveis diagnosed in the postoperative period, the clinician should begin pla nn ing for itsmanagement, including referral to a neurologist or a microneurosurgeon. 74

SINUS COMMUNICATION

After extraction of maxillary posterior teeth, sinus communications are common, oftenunrecognized, and do not require treatment. Persi ste nt, symptomatic sinus communi-cations are rare, with a frequency of less than 1%. 23 Oral-antral communications mayresult from excessive manipulation of the operative site or poor technique. Communi-cations typically result from intimate anatomic associations between the roots of theteeth and the floor of the maxillary sinus, especially when the antrum is pneumatized.

As with displacement of teeth into the maxillary sinus, prevention of such commu-nications starts with identification of the at-risk patient. Meticulous evaluation of preoperative radiographs for evidence of encroachment of the roots on the floor of the sinus should alert the clinician to the likelihood of this complication. On extraction,the socket should be curetted delicately if necessary. If the tooth is not removedcompletely, judicious exploration should be undertaken, so as not to displace theremnant into the sinus, or perforate the sinus floor while attempting to remove the frag-ment. A self-limiting communication may be an unavoidable side effect of toothremoval because of the anatomic relationship between the roots and the sinus, espe-cially in patients of increasing age, because of the increased size of the antrum.



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Table 3Pain medication

Medication Mode of Action Indication Adult Dose Pediatric Dose Acetaminophen

(APAP)Central prostaglandin

synthesis inhibitionMild to moderate

pain325–650 mg every 4–6 h

not to exceed 4 g daily,2 g daily in liver-compromised patients

6 mo

age 5–10 mg/kevery 6–8 h (s50 mg/1.25 mL5 mL)

Opioids: codeinehydrocodoneoxycodone

Opioid receptorantagonist

Moderate to severepain

In combination with APAP:30 mg codeine, 300 mgAPAP 5 mg hydrocodone,500 mg APAP (Vicodin)5 mg oxycodone 325 mg

APAP (Percocet)

Codeine, 0.5–1 mcombined withabove dosing)


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Diagnosis of a sinus communication is often made by having the patient force airthrough the nasal cavity while the nares are deliberately closed. If a large communica-tion exists, air bubbles are visible in the socket, although this method may prove inef-fective for small communications. If a communication is discovered, either by tactilesensation or f or ced air maneuver, the size of the defect and patient complaint guidethe treatment. 75 As a general principle, any patient with a communication should beplaced on sinus precautions, including broad spectrum antibiotics (see Table 2 ) andnasal decongestants (pseudoephedrine). Most oroantral communications heal spon-taneously with little intervention.

The clinician should monitor the patient closely over the postoperative period toconfirm closure of the oroantral communication. If an oroantral fistula develops,standard procedures to produce a layered closure of the wound and managementof the sinus are indicated. The size of the clinical fistula is smaller than the bonydefect.

TEMPOROMANDIBULAR DISORDER

Can a dentist cause a temporomandibular disorder (TMD)? The short answer is yes. Ina survey of 230 patients with a TMD, 30% related the onset of their symptoms to someform of dental treatment. 75 Patients who undergo difficult mandibular exodontiaprocedures can develop temporomandibular joint (TMJ) symptoms immediately afterthe procedure. This situation often results from trauma to the TMJ that occurs duringmandibular extractions if no support is given to counteract the lateral forces duringdifficult and prolonged exodontia procedures.

These lateral forces can be counteracted by providing support to the mandible withthe other hand or the use of a bite block. 76,77 If you have failed to use a bite block,patients often tell you that they are experiencing joint pain while undergoing a difficultlower extraction. The risk of developing a postextraction TMJ problem is highest inthose patients who have a previous history of TMJ problems, and those patientsshould be advised before any extensive procedure that they may develop a recurrenceor exacerbation of their preexisting disease; be aware that this complication can alsooccur in someone with no preexisting TMD condition. It is also prudent to ask a ques-tion directly to the patient about any preexisting history of TMD disorders beforebeginning any complicated exodontias, to perform a brief TMJ examination on all

patients before beginning any dental or oral surgical procedures, and to documentthese findings in your patient records (before rendering any patient treatment). Thebest way to limit or eliminate TMJ problems as a potential postsurgical complicationis to attempt to do one or all (if needed) of the following.

A. Limit the amount of forces used during exodontiaB. Always use a bite block for mandibular extractionC. Allow the patient to rest their joint during the procedure if the procedure is taking

considerable timeD. Surgically remove some buccal or palatal bone or section the tooth involved to

allow you to decrease the forces needed to complete the extraction.If a patient returns to your office after a difficult exodontia procedure showing TMJ

symptoms, such as TM joint pain or, limitation of opening, they should be placed onthe usual TMJ/TMD treatment regimen. The usual TMJ regimen should include:

1. Recommend the patient be placed on a soft nonchew diet for 1 to 2 weeks2. Apply moist heat to the affected side several times a day



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3. Prescription for nonsteroidal antiinflammatories for 2 weeks or more4. Prescription for muscle relaxant.

The patient should be followed up until symptoms are significantly improved, and allpatient encounters and responses should be documented in the patient records.

TRISMUS

The inability to fully open one’s mouth (40 mm is considered the norm) after difficultsurgical exodontia is not unusual, especially in the immediate postoperative period.This situation is caused directly by swelling that occurs and most likely often peaks at24 to 48 hours.

The severity of the facial swelling is caused by multiple factors, including length of surgical procedures, amount of soft tissue resection, and the complexity of the proce-dure. One week after most surgical extractions or surgical procedures, most patientsshould return to their presurgical level of mouth opening. If this situation does notoccur and the patient presents with limited jaw opening (


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Multiple factors and reasons have been explained as possible causes, including:

Surgeon’s experience level Anatomic variants, such as thin lingual plate of mandible or sinus that is close tomolar roots

Excessive forces Poor visualization because of inadequate surgical exposure.

In all cases, when the tooth or root disappears, good suction and light should beused to search the extraction socket before assuming the tooth has been displaced.Often, simply by gently irrigating the socket and using a fine suction tip and good light,the missing tooth/root can be seen and retrieved. If the tooth has been displaced intothe infratemporal space, it would be best to abort the procedure and close the site and

refer the patient to an oral and maxillofacial surgeon. Most often, the tooth is allowedto fibrose, and then a CT scan is taken to determine the exact location of the tooth anda decision is made on whether retrieval is necessary. If a decision is made to searchand retrieve the displaced tooth, this most often requires a hemicoronal flap,; althoughoccasionally it can be accessed through an intraoral approach.

Teeth or roots can often be pushed out through a thin lingual mandibular plate intothe sublingual space. If this situation occurs, this displaced tooth or root can often bepalpated in the floor of the mouth and gently guided back into the socket. If thisstrategy is not possible, timely referral to an oral and maxillofacial surgeon is againadvised.

FOREIGN BODIES

Within the past few years, because of the advent of implant placement, we have seenan increased incidence of foreign bodies displaced into the maxillary sinus, such asparalleling pins, implants, and roots. Our discussion is limited to the retrieval of such items. The key to prevention of such complications is proper preoperative plan-ning. This planning begins with thorough clinical examination, study models, pictures,and most importantly adequate and current radiographic imaging. Periapical,occlusal, and panorex images may not be adequate. The information required toplan a complex or even a simple case of placement of multiple maxillary posteriorimplants may include CT scans or cone beam studies. These studies allow the dentistto view the surgical site in a three-dimensional (3D) format. The information gatheredfrom these studies not only gives information about implant selection, placement, andneed for sinus augmentation but also reveals disease that otherwise may be missed.Chronic sinusitis, infected sinus, cyst, polyps, bony defects, and quality and quantityof bone can be evaluated with these studies.

Box 1Various anatomic areas into which teeth have been displaced

Maxillary sinus

Sublingual space

Submandibular space

Intratemporal space

Lateral pharyngeal space

Floor of nose



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Selection of the proper implant, based on available bone, is key to prevention of mishaps ( Box 2 ). Once the dimensions of the implant site are known, the properdepth to drill prevents the dentist from entering the maxillary sinus. It is advisableto have a 0-mm to 2-mm distance between implant and sinus floor. Even when prop-erly planned an implant may still escape into the maxillary sinus. If this situationoccurs, abort the procedure and reposition the patient with the occlusal plan parallelto the floor. Suction can be tried to pull the implant into the oral cavity, but thesuction has to be powerful. If this strategy fails, take a radiograph. It may be periap-ical, occlusal, or panorex, depending on what is available in the office. If the implantwas partially displaced, you should be able to locate it with these radiographictechniques.

However, if you cannot locate the implant, it may have displaced to the posterior of the maxillary sinus. Ask the patient to bend their head forward between their kneesand repeat the radiographs. This maneuver should move the implant into the anteriorsinus. If the implant is located close to the surgical site, reflecting a buccal flap andcreating a buccal window may be used to retrieve the implant. If the implant cannotbe located, check the oral cavity, gauze drapes, and suction canister for the implant.If the implant still cannot be located, the authors suggest suturing the surgical fold,placing the patient on antibiotics, pain medication, and sinus medication, and referringthem to a radiologist or oral and maxillofacial surgeon for sinus radiographs. Based onyour surgical training, a decision has to be made on referring the patient for treatmentor doing it yourself.

On locating the implant radiographically, a surgical procedure, like a Caldwell-Lucprocedure, may be required to remove the implant. If the implant was displaced

because of insufficient bone height, sinus augmentation can be performed at thetime and the implant placed later. If bone is adequate, then the proper implant canbe selected and placed at this time.

NEEDLE BREAKAGE

Needle breakage is an uncommon occurrence in dentistry. Anesthetic techniquesused in dentistry, especially the interior alveolar and lingual nerve blocks, suggest con-tacting the bone, then withdrawing the needle 1 mm before injecting the solution. Also,with a bite block in the mouth, when administering inferior alveolar nerve block, theneedle may have to be bent to deliver the anesthetic into the pterygomandibulardepression. In the pediatric population the patient may not sit still, and you shouldwait until movement has stopped before delivering an anesthetic.

Box 2Steps to follow: foreign body displaced into maxillary sinus

1. Adequately evaluate posterior maxilla

2. Select proper implant

3. Suction, oral cavity

4. Radiographic studies

5. Retrieve implant, close surgical site

6. Antibiotics, pain medication, sinus medication

7. Referral to oral and maxillofacial surgeon

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Avoid inserting small-diameter needles up to the hub, because this increases thechance of breakage. Once the needle has been inserted in the tissue, try to reduceredirecting the needle. This action can tear muscle, vessels, or nerves and maycontribute to hematoma formation. If the needle has to be removed and the anestheticagent delivered in the new p osition, try not to bend the needle, but if it must be bent,do not bend it at the hub. 79

If breakage occurs, try to remove the needle immediately if part of it is visible. In theoffice avoid lengthy procedures, which may complicate the situation. Close the surgicalsite and refer the patient to your hospital or to a surgeon. However, the patient shouldbe informed of the occurrence and made aware of your plan for removal of the needle.Having admitting privileges at a local hospital can be advantageous, because one canparticipate in the patient care. To retrieve the needle, a CT scan with 1.5-mm slices thatcan be reconstructed three-dimensionally is necessary. If the patient is not symptom-atic a delayed removal can be planned. This strategy helps the tissue stabilize andencapsulate the needle. When immediate removal is necessary, the patient shouldbe admitted to the hospital for management. The removal of a needle should be per-formed by someone who has experience in the procedure because otherwise undesir-able trismus and even infection may result and prevent an early successful operation.Radiology services, including the use of a C arm and localizing needles, are needed.

Needle Breakage Avoid movement of patient Avoid insertion to close the hub Avoid bending the needle.

Management Removal of hemostat Notify patient Document event Referral to experienced surgeon Radiographic films: 3D CT Delayed removal.

REFERENCES

1. Sisk AL, Hammer WB, Shelton DW, et al. Complications following removal ofimpacted third molars: the role of the experience of the surgeon. J Oral MaxillofacSurg 1986;44:855–9.

2. Larsen PE. The effect of chlorhexidine rinse on the incidence of alveolar osteitisfollowing the surgical removal of impacted mandibular third molars. J Oral Max-illofac Surg 1991;49:932–7.

3. Capuzzi P, Montebugnoli L, Vaccaro MA. Extraction of impacted 3rd molars–a longitudinal prospective study on factors that affect postoperative recovery.Oral Surg Oral Med Oral Pathol 1994;77:341–3.

4. Nordenram A, Hultin M, Kjellman O, et al. Indications for surgical removal of themandibular third molar. Swed Dent J 1987;2:23–9.

5. Ng F, Bums M, Ken WJ. The impacted lower third molar and its relationship totooth size and arch form. Eur J Orthod 1986;8:254–8.

6. Forsberg CM. Tooth size, spacing, and crowding in relation to eruption or impac-tion of third molars. Am J Orthod Dentofacial Orthop 1988;94:57–62.

7. Venta I, Turtola L, Ylipaavalniemi P. Radiographic follow-up of impacted thirdmolars from age 20 to 32 years. Int J Oral Maxillofac Surg 2001;30:54–7.



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8. Lysell L, Rohlin M. A study of indications used for removal of the mandibular thirdmolar. Int J Oral Maxillofac Surg 1988;17:161–4.

9. Hattab FN, Abu Alhaija ES. Radiographic evaluation of third molar eruptionspace. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:285–91.

10. Ades AG, Joondeph DR, Little RM, et al. A long-term study of the relationship ofthird molars to changes in the mandibular dental arch. Am J Orthod DentofacialOrthop 1990;97:323–35.

11. Larsen PE, Mesieha ZS, Peterson LJ, et al. Impacted third molars: radiographicfeatures used to predict extraction difficulty. J Dent Res 1991;70:551–7.

12. Amler MH. The age factor in human extraction wound healing. J Oral Surg 1977;35:193–7.

13. Nordenram A. Postoperative complications in oral surgery. Swed Dent J 1983;7:109–14.

14. Goldberg MH, Nemarich AN, Marco WP. Complications after mandibular thirdmolar surgery: a statistical analysis of 500 consecutive procedures in privatepractice. J Am Dent Assoc 1985;111:277–9.

15. Bruce RA, Frederickson GC, Small CS. Age of patients and morbidity associatedwith mandibular third molar surgery. J Am Dent Assoc 1980;101:240–5.

16. Osborn TP, Frederickson C, Small IA, et al. A prospective study of complicationsrelated to mandibular third molar surgery. J Oral Maxillofac Surg 1985;43:767–9.

17. Hinds EC, Frey KF. Hazards of retained third molars in older persons: report of 15cases. J Am Dent Assoc 1980;101:246–50.

18. McGrath C, Comfort MB, Lo EC, et al. Changes in life quality following third molarsurgery–the immediate postoperative period. Br Dent J 2003;194:265–8.

19. Shafer DM, Frank ME, Gent JF, et al. Gustatory function after third molar extrac-tion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:419–28.20. White RP, Shugars DA, Shafer DM, et al. Recovery after third molar surgery: clinical

and health-related quality of life outcomes. J Oral Maxillofac Surg 2003;61:535–44.21. Partridge CG, Campbell JH, Alvarado F. The effect of platelet-altering medica-

tions on bleeding from minor oral surgery procedures. J Oral Maxillofac Surg2008;66:93–7.

22. Dodson TB. Strategies for managing anticoagulated patients requiring dentalextractions: an exercise in evidence-based clinical practice. J Mass Dent Soc2002;50:44–50.

23. Susarla SM, Blaeser BF, Magalnick D. Third molar surgery and associatedcomplications. Oral Maxillofac Surg Clin N Am 2003;15:177–86.

24. Rodesch G, Soupre V, Vazquez MP, et al. Arteriovenous malformations of thedental arcades. The place of endovascular therapy: results in 12 cases are pre-sented. J Craniomaxillofac Surg 1998;26:306–13.

25. Forsgren H, Heimdahl AN, Johansson B, et al. Effect of application of cold dress-ings on the postoperative course in oral surgery. Int J Oral Surg 1985;14:223–8.

26. Peterson LJ. Post-operative patient management. In: Peterson LJ, Ellis E III,Hupp JR, et al, editors. Contemporary oral and maxillofacial surgery. 3rd edition.New York: Mosby; 1998. p. 249–56.

27. Haug RH, Perrott DH, Gonzalez ML, et al. The American Association of Oral andMaxillofacial Surgeons Age-Related Third Molar Study. J Oral Maxillofac Surg2005;63:1106–14.

28. Hooley JR, Francis FH. Betamethasone in traumatic oral surgery. J Oral Surg1969;27:398–403.

29. Huffman GG. Use of methylprednisolone sodium succinate to reduce postopera-tive edema after removal of impacted third molars. J Oral Surg 1977;35:198–9.

Pierse et al90


17/19

30. Pedersen A. Decadron phosphate in the relief of complaints after third molarsurgery. Int J Oral Surg 1985;14:235–40.

31. Beirne OH, Hollander B. The effect of methylprednisolone on pain, trismus, andswelling after removal of third molars. Oral Surg Oral Med Oral Pathol 1986;61:134–8.

32. Bustedt H, Nordenram A. Effect of methylprednisolone on complications afterremoval of impacted mandibular third molars. Swed Dent J 1985;9:65–9.

33. Alexander RE, Throndson RR. A review of perioperative corticosteroid use indentoalveolar surgery. Oral Surg Oral Med Oral Pathol 2000;90:406–15.

34. Green SM, editor. Tarascon pocket pharmacopoeia. Redlands (CA): TarasconPublishing; 2007.

35. Salerno A, Hermann R. Efficacy and safety of steroid use for postoperative pain relief.Update and review of the medical literature. J Bone Joint Surg Am 2006;88:1361–72.

36. Nordenram A, Grave S. Alveolitis sicca dolorosa after removal of impactedmandibular third molars. Int J Oral Surg 1983;12:226–31.

37. Heimdahl A, Nord CE. Treatment of orofacial infections of odontogenic origin.Scand J Infect Dis 1985;46(Suppl):101–5.

38. Ren YF, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molarsurgery: a meta-analysis of randomized controlled clinical trials. J Oral MaxillofacSurg 2007;65:1909–21.

39. Sweet JB, Butler DP, Drager JL. Effects of lavage techniques with third molarsurgery. Oral Surg Oral Med Oral Pathol 1976;42:152–68.

40. Loukota RA. The incidence of infection after third molar removal. Br J Oral Max-illofac Surg 1991;29:336–7.

41. Happonen RP, Backstrom AC, Ylipaavalniemi P. Prophylactic use of phenoxy-

methyl penicillin and tinidazole in mandibular third molar surgery, a comparativeplacebo controlled clinical trial. Br J Oral Maxillofac Surg 1990;28:12–5.42. Bystedt H, Nord CE. Effect of antibiotic treatment on postoperative infections after

surgical removal of mandibular third molars. Swed Dent J 1980;4:27–38.43. Bystedt H, yon Konow L, Nord CE. Effect of tinidazole on postoperative compli-

cations after surgical removal of impacted mandibular third molars. Scand JInfect Dis 1981;26(Suppl):135–9.

44. Hellem S, Nordenra A. Prevention of postoperative symptoms by general antibi-otic treatment and local bandage in removal of mandibular third molars. Int J OralSurg 1973;2:273–8.

45. Kariro GS. Metronidazole (Flagyl) and Arnica montana in the prevention of post-surgical complications; a comparative placebo controlled clinical trial. Br J OralMaxillofac Surg 1984;22:42–9.

46. Krekmanov L, Nordenram A. Postoperative complications after surgical removalof mandibular third molars. Int J Oral Maxillofac Surg 1986;15:25–9.

47. Krekmanov L, Hallander HO. Relationship between bacterial contamination andalveolitis after third molar surgery. Int J Oral Surg 1950;9:274–80.

48. Krekmanov L. Alveolitis after operative removal of third molars in the mandible. IntJ Oral Surg 1981;10:173–9.

49. Macgregor AJ, Addy A. Value of penicillin in the prevention of pain, swelling and

trismus following the removal of ectopic mandibular third molars. Int J Oral Surg1980;9(3):166–72.

50. Rood JP, Murgatroyd JM. Metronidazole in the prevention of “dry socket.” Br JOral Surg 1979;17:62–70.

51. Flynn T. Principles of management of odontogenic infections. In: Miloro M,Ghali GE, Larsen P, et al, editors. Peterson’s principles of oral and maxillofacialsurgery. 2nd edition. Ontario (Canada): BC Decker; 2004. p. 277–93.



18/19

52. Safdar N, Meechan JG. Relationship between fractures of the mandibular angleand the presence and state of eruption of the lower 3rd molar. Oral Surg Oral MedOral Pathol Oral Radiol Endod 1995;79:680–4.

53. Tevepaugh DB, Dodson TB. Are mandibular third molars a risk factor for anglefractures? A retrospective cohort study. J Oral Maxillofac Surg 1995;53:646–9.

54. Peterson LJ. Principles of management of impacted teeth. In: Peterson LJ,Ellis E III, Hupp JR, et al, editors. Contemporary oral and maxillofacial surgery.4th edition. St Louis (MO): CV Mosby; 2003. p. 184–213.

55. Knutsson K, Lysell L, Rohlin M. Postoperative status after partial removal of themandibular third molar. Swed Dent J 1989;13:15–22.

56. Nitzan DN. On the genesis of “dry socket.” J Oral Maxillofac Surg 1983;41:706–10.

57. Sweet JB, Butler DP. The relationship of smoking to localized osteitis. J Oral Surg1979;37:732–5.

58. Meechan JG, MacGregor ID, Rogers SN, et al. The effect of smoking on imme-diate postextraction socket filling with blood and the incidence of painful socket.Br J Oral Maxillofac Surg 1988;26:402–9.

59. Swanson AE. A double-blind study on the effectiveness of tetracycline in reducingthe incidence of fibrinolytic alveolitis. J Oral Maxillofac Surg 1989;47:165–7.

60. Goldman DR, Kilgore DS, Panzer JD, et al. Prevention of dry socket by localapplication of lincomycin in Gelfoam. Oral Surg Oral Med Oral Pathol 1973;35:472–4.

61. Hall HD, Bildman BS, Hand CD. Prevention of dry socket with local application oftetracycline. J Oral Surg 1971;29:35–7.

62. Mitchell L. Topical metronidazole in the treatment of “dry socket.” Br Dent J 1984;156:132–4.63. Larsen PE. Alveolar osteitis after surgical removal of impacted mandibular third

molars. Identification of the patient at risk. Oral Surg Oral Med Oral Pathol1992;73:393–7.

64. Berwick JE, Lessin ME. Effects of a chlorhexidine gluconate oral rinse on the inci-dence of alveolar osteitis in mandibular third molar surgery. J Oral MaxillofacSurg 1990;48:444–8.

65. Hita-Iglesias P, Torres-Lagares D, Flores-Ruiz R, et al. Effectiveness of chlorhex-idine gel versus chlorhexidine rinse in reducing alveolar osteitis in mandibular

third molar surgery. J Oral Maxillofac Surg 2008;66:441–5.66. Shepherd J. Pre-operative chlorhexidine mouth rinses reduce the incidence of

alveolar osteitis. Evid Based Dent 2007;8:43.67. Halpern LR, Dodson TB. Does prophylactic administration of systemic antibiotics

prevent postoperative inflammatory complications after third molar surgery?J Oral Maxillofac Surg 2007;65:177–85.

68. Rutkowski JL, Fennell JW, Kern JC, et al. Inhibition of alveolar osteitis in mandibulartooth extraction sites using platelet-rich plasma. J Oral Implantol 2007;33:116–21.

69. Kipp DP, Goldstein BH, Weiss WW Jr. Dysesthesia after mandibular third molarsurgery: a retrospective study and analysis of 1,377 surgical procedures. J Am

Dent Assoc 1980;100:185–92.70. Wofford DT, Miller RI. Prospective study of dysesthesia following odontectomy of

impacted mandibular third molars. J Oral Maxillofac Surg 1987;45:15–9.71. Mason DA. Lingual nerve damage following lower third molar surgery. Int J Oral

Maxillofac Surg 1988;17:290–4.72. Robinson PP. Observations on the recovery of sensation following inferior alveolar

nerve injuries. Br J Oral Maxillofac Surg 1988;26:177–89.

Pierse et al92


19/19

73. Rood JP. The radiological prediction of inferior alveolar nerve injury during thirdmolar surgery. Br J Oral Maxillofac Surg 1990;28:20–5.

74. Blaeser BF, August MA, Donoff RB, et al. Panoramic radiographic risk factors forinferior alveolar nerve injury after third molar extraction. J Oral Maxillofac Surg2003;61:417–21.

75. PetersonLJ.Prevention and management of surgical complications. In: Peterson LJ,Ellis E III, Hupp JR, et al, editors. Contemporary oral and maxillofacial surgery. 3rdedition. New York: Mosby; 1998. p. 257–75.

76. Wright E. Manual of temporomandibular disorders. Ames (IA): Blackwell; 2005.77. Spinnato G, Alberto PL. Complications of dentoalveolar surgery in Fonseca. 2nd

edition, vol. 1. Oral and maxillofacial surgery. St. Louis (MO): Elsevier; 2009.78. Henderson SJ. Risk management in clinical practice. Part II.Oral surgery. Br Dent J

2011;210(1).79. Thoma KH. Local anesthesia. Oral surgery, vol. 1. Boston (MA): Mosby; 1969.


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